Miss Diagnosis

Get Your Hands off My Health Care Reform

These days, health care isn’t just about diagnosing and treating disease. Good health care providers know they must first address the patient’s needs, which, ironically enough, sometimes involves not making a diagnosis. After all, diagnoses become a part of the patient’s medical record, which can be reviewed by insurers. If insurers see an expensive diagnosis, they could drop the patient or deny coverage.

Because of this, some health providers dole out diagnoses carefully. A pediatric provider may delay making an asthma diagnosis and instead write “recurring bronchitis” on a child’s chart, knowing that asthma can be a chronic disease that insurers will consider a pre-existing condition. Others avoid diagnosing patients with obesity, because most insurers won’t pay for obesity management. And some women forego genetic testing for the genes that cause breast cancer because, if they are found to carry the gene, they may lose coverage.

These insurance practices harm patients and tie providers’ hands, crippling the delivery of health care in this country. That’s why many of us who actually take care of patients sighed with relief when health reform was signed into law: The end to being held hostage by pre-existing conditions was finally in sight.

But opponents of health reform want to see the new law go bye-bye. They are arguing that the bill is unconstitutional in an attempt to get the courts to repeal the law. Yet these opponents represent a disproportionately noisy minority. A study from the Kaiser Family Foundation and Harvard School of Public Health found that most Americans oppose defunding the bill. Some portions of the bill, such as subsidies and Medicare drug discounts, are supported by as much as 85 percent of the public.

Name-calling doesn’t change the fact that this is the evolutionary link between the expensive, discriminatory, failing health system of yesterday and the affordable, accessible, effective health system of tomorrow.

Revisiting the Case for Reform

We’re all familiar with horror stories of insurance companies denying lifesaving treatments or refusing payment to bankrupt families. The number of uninsured Americans climbs higher each year and swelled above 50 million in 2009. Studies show that a person who lacks health coverage is less likely to seek or receive health care and more likely to die during illness.

Uninsured folks are more likely to suffer longer, less effective hospital visits, and they’re more likely to be charged much higher prices for the same care than their insured counterparts. Some of us have even held hands with these uninsured people as they take their last breath or deliver their first child without having had a stitch of prenatal care, or as they suffer from untreated pain in a crowded emergency waiting room. What can we do about it?

Some wanted to see insurance companies die off like the trilobite, leaving behind only their bizarre fossils for future generations to puzzle over, wondering how something like this could have ever existed. Yet the political climate wasn’t hot enough to produce an extinction. Instead, we got a smaller but significant mutation in our health care system called the Patient Protection and Affordable Care Act [click here to read the law’s full text]. Opponents of health reform call it job-killing or socialism or unconstitutional, but this name-calling doesn’t change the fact that the legislation is the evolutionary link between the expensive, discriminatory, failing health system of yesterday and the affordable, accessible, effective health system of tomorrow.

The law isn’t perfect, and it alone won’t produce a perfect organism. The ideal system requires future mutations to the health reform law. Yet the reform law offers crucial provisions that will ensure survival. It leverages important regulations over insurance companies, prohibiting them from discriminating on the basis of pre-existing conditions and requiring them to spend 80 to 85 percent of revenue from premium payments on actual health care. It extends insurance coverage to millions of Americans through subsidies and Medicaid. There are lots of other little whiskers attached to the bill as well, such as increasing the number of primary care providers, extra funding for educational programs and innovative health care delivery models.

Similar cries of unconstitutionality were made when Congress tried to enact child labor laws, and anti-segregation laws, and Social Security, and Medicare, and even seat belt and helmet laws.

How does the bill manage to regulate insurance, expand coverage and, according to the Congressional Budget Office, cut the federal deficit by $1.2 trillion over the next two decades? First, “safety net” funding for the uninsured will be diverted into premium subsides and Medicaid funds instead. Another chunk is paid for by reforming inefficiencies and waste in Medicare. But the glue holding much of health reform’s financial solvency together is the individual mandate.

Shared Risk and Responsibility

There’s been some fuss over the individual mandate lately, because it requires the majority of Americans to obtain insurance or pay a fee. Health reform in today’s economic climate doesn’t work without the individual mandate, because we need to pull more people (especially the young, healthy ones) into the insurance pool to share risk and control costs. People without insurance, after all, are paid for one way or another. Uninsured people spend enormous sums for out-of-pocket expenses, and the remainder is covered by taxpayers (who pay for things like uncompensated care and tax write-offs for hospitals) and consumers (who pay inflated insurance and health care prices to offset those unable to pay). There are other hidden costs too, because “safety net” care has been shown to be more expensive and less effective than care of the insured.

The individual mandate is the most controversial piece of the health reform, so it’s an easy target for health reform opponents to pick on in front of the American public. Does this make it unconstitutional? The Supreme Court will have the final say, yet the majority of federal judges seeing lawsuits against health care reform have either dismissed these constitutionality challenges or upheld the new law. Furthermore, more than 100 of the nation’s leading legal scholars released a joint statement demonstrating the constitutionality of the individual mandate. The statement argues that, because of the broad powers outlined in the Constitution’s Commerce Clause, “Congress’s power to regulate the national healthcare market is unambiguous.”

Those whining the loudest about the individual mandate are those who claim to value individual responsibility above all. Here’s a chance to hold Americans responsible for obtaining insurance.

Ultimately, legal scholars warn that anti-reform court rulings like the ones in Virginia and Florida represent radical judicial activism that could unravel 200 years of settled law. This would not only erode the government’s ability to regulate the multi-trillion dollar health care industry but all other industries as well.

It’s worth remembering that similar cries of unconstitutionality were made when Congress tried to enact child labor laws, and anti-segregation laws, and Social Security, and Medicare, and even seat belt and helmet laws. There are those who believe that the federal government’s job is to intervene only to protect their own wealth and power, and they flare up whenever the government intervenes on behalf of marginalized, minority or vulnerable people.

Still, some people don’t care about the unconstitutional quibble. After all, these little spats are for think tanks and briefcases who aren’t facing the real world of being uninsured or being forced to shell out premium payments. As is usually the case in America, low- and middle-income people have the most to gain and the most to lose from health reform, so no advocate of health reform can write off the unconstitutionality debate without at least addressing concerns over the mandate.

There are many exceptions to the individual mandate, like exemptions for low-income people or folks who can’t find affordable plans. There will be considerable subsidies and new, affordable options for middle-income people. But yes, at the end of the day, the government will require most of us to have health insurance. It’s called a shared-responsibility model, meaning the responsibility for insuring Americans is shared by government, employers and individuals.

States can actually save money under the new Medicaid provisions, because the feds will be picking up the tab for patients who are paid for by state programs.

Oddly enough, those whining the loudest about the individual mandate are those who claim to value individual responsibility above all. Here’s a chance to hold Americans responsible for obtaining insurance. But no, say reform haters—let’s protect people’s right to remain uninsured through their healthy years so they can attempt to obtain insurance when they’re old and sick. (Hey, and good luck with those premiums!) Taxpayers and consumers will just have to eat the cost of uncompensated care to keep the Big Brother nanny state from telling us what to do, man.

Medicaid

Another anti-reform argument is that federal requirements for state Medicaid programs are bankrupting the states. Scary stories about states refusing to pay for certain procedures have been paraded around—without a thought as to how these Medicaid recipients would fare if they were disenrolled from Medicaid altogether. Federal requirements for Medicaid eligibility are conveniently blamed for budget shortfalls, shifting the focus away from the real culprit, which is the rising cost of health care in an economic recession. Yet rather than allowing health reform to exert its cost-controlling measures to lower expenditure and improve outcomes, health reform opponents argue that states should disenroll Medicaid beneficiaries and sue the government on the grounds of unconstitutionality instead.

In this case, the unconstitutionality claim is being made because, in order for the states to receive help from the federal government when it comes to funding their Medicaid programs, states can’t restrict eligibility requirements beyond where they are now. Unfortunately for health reform opponents, there’s nothing unconstitutional about the feds giving away money with strings attached.

Granted, squashing the constitutionality question doesn’t solve the problem at hand. States are still strapped for cash, which means that state and federal governments will have to problem-solve regarding Medicaid eligibility and efficiency. However, this isn’t a reason to repeal the whole of health reform legislation. Quite the opposite. The inflated cost of health care led to this financial pickle in the first place, making the regulatory and cost-containing measures of the law more crucial than ever. In fact, a Kaiser Commission report projects that states can actually save money under the new Medicaid provisions, because the feds will be picking up the tab for patients who are paid for by state programs.

As the Law Unfolds, the System Evolves

Finally, some argue that the health care reform law, although well-intentioned, is hurting more than it’s helping. Employers are dropping coverage. Waivers are being handed out. Locusts are swarming the skies. Yet bear in mind: Employers will not be allowed to drop coverage when the full regulations take effect. And even without a legal requirement, most employers today voluntarily offer competitive benefits packages to attract the best and brightest. This won’t change under health reform.

Still, there will undoubtedly be more growing pains before the new law is fully implemented, and they must be addressed as they crop up. For instance, when some insurers stopped selling child-only policies after the law prohibiting denial of coverage for children with pre-existing conditions kicked in, states like California fought back by establishing open-enrollment periods, which successfully kept child-only policies on the market. More adjustments like these will need to be made as health reform unfurls. These headaches are not a reason to repeal health reform. In fact, a Department of Health and Human Services analysis revealed that 129 million people could be denied affordable coverage if health reform is rescinded. This includes 2 million children with pre-existing conditions.

Children with asthma and women with breast cancer genes need insurance like everyone else. The 50 million uninsured Americans shouldn't be dying in hospital beds more frequently than their insured neighbors. Emergency rooms must be free to handle actual emergencies rather than flooded by patients in search of primary care. These are the issues that made the new law necessary—and they'll still be waiting for us if the Patient Protection and Affordable Care Act is taken away.

Despite its brilliant name, this column is not intended to prevent, diagnose or treat herpes. Or any other diseases, for that matter.